Endocrinology Flashcards
1
Q
Causes of hyponatraemia with >20mmol urinary sodium
A
Addison’s
Diuretics
Renal failure
Euvolaemic - hypothyroidism, SIADH
2
Q
Prolactinoma treatment
A
Dopamine agonists (cabergoline, bromocriptine)
Trans-sphenoidal surgery
3
Q
Prolactinoma symptoms?
A
Amenorrhoea, galactorrhoea, impotence, osteoporosis (women), loss of libido
4
Q
What does a a dexamethasone test entail and what is it used for?
A
Suspected Cushing’s
Low dose 1mg, high dose 8mg
5
Q
What does a low cortisol following high dose dexamethasone suggest?
A
Cushing’s Disease (i.e. pituitary adenoma)
6
Q
What does a high/normal cortisol following high dose dexamethasone suggest?
A
High ACTH: ectopic ACTH (small cell lung carcinoma)
Low ACTH: Cushing’s Disease
7
Q
What are the ACTH dependent and ACTH independent causes of Cushing’s?
A
Dependent: Pituitary adenoma (Cushing’s disease), ectopic ACTH (small cell carcinoma)
Independent: iatrogenic steroids, adrenal adenoma
8
Q
What are two syndromes associated with hypothyroidism?
A
Down’s
Turner’s
9
Q
Causes of primary hypothyroidism
A
Hashimoto's hypothyroidism Subacute thyroiditis (De Quervain's) Riedel thyroiditis Post-thyroidectomy or radioiodine treatment Drug therapy e.g. lithium, carbimazole) Dietary iodine deficiency
10
Q
What are Sertoli cells stimulated by and what do they produce?
A
Stimulated by FSH
Produce sperm and jnhibins A and B
11
Q
What are Leydig cells stimulated by and what do they produce?
A
Stimulated by LH
Produce testosterone
12
Q
What is the role of Inhibin
A
Negative feedback on pituitary to decrease FSH
13
Q
What is the role of FSH and LH in the female?
A
LH stimulates theca cells to produce androgens
FSH stimulates follicular development and oestrogen production (from androgens) in granulosa cells
14
Q
When does puberty in boys start and finish?
A
10-14
15-17
15
Q
What antibodies are seen in Hashimoto’s?
A
Anti-TPO
16
Q
35-year-old woman is found to have a blood pressure of 180/110 mmHg. She complains of feeling tired and weak. Routine bloods show hypokalaemia
A
Primary hyperaldosteronism
17
Q
40-year-old woman presents with lethargy, weakness and weight loss. On examination her blood pressure is 80/50 mmHg and there is hyperpigmentation of the skin
A
Addison’s
18
Q
Features of primary hyperaldosteronism
A
Tiredness
Hypertension (due to resorption of sodium)
Hypokalaemia - muscle weakness
Alkalosis
19
Q
Primary hyperaldosteronism investigations and management
A
Aldosterone/renin ratio - raised aldosterone, low renin (negative feedback from retained sodium)
CT scan and Adrenal Venous Sampling (AVS) - uni or bilateral
Adrenal adenoma - surgery
Bilateral adrenocortical hyperplasia - aldosterone antagonist (spironolactone)
20
Q
A 60-year-old woman is investigated for heat intolerance and weight loss. The free T4 level is elevated and the TSH is suppressed. Nuclear scintigraphy reveals an enlarged thyroid gland with patchy uptake. Diagnosis?
A
Toxic multinodular goitre
21
Q
What antibodies are present in Grave’s disease?
A
TSH receptor antibodies
22
Q
What electrolyte imbalance can sarcoidosis cause?
A
Hypercalcaemia
23
Q
What is the action of SGLT-2 inhibitors?
A
Inhibits reabsorption of glucose in the kidney
Risk of weight loss, genital infections and DKA (increases glucose secretion by kidneys)
Don’t give in thrush patients!
24
Q
Action of metformin?
A
Increases insulin sensitivity
Decreases hepatic gluconeogenesis
25
Characteristics of sick euthyroid syndrome?
Systemic illness
Inappropriately normal TSH with low T3
Returns to normal when recovers from underlying illness
26
What are the endocrine side effects of corticosteroids?
```
Impaired glucose control (anti-insulin effect)
Weight gain and appetite
Hirsutism
Hyperlipidaemia
Cushing's syndrome
```
27
What are the non-endocrine side effects of corticosteroids?
```
Glucocorticoids
Avascular necrosis of the femoral head
Psych: depression, mania, insomnia, psychosis
Immunosuppression
GI: peptic ulceration, acute pancreatitis
Eyes: glaucoma, cataracts
Intracranial hypertension
Neutrophilia
Osteoporosis
Growth suppression in children
```
Mineralcorticoids
Hypertension
Fluid retention
28
What is the action of sulfonylureas and who should they be avoided in?
Increases insulin secretion by beta cells
Avoid if pregnant or breastfeeding or at risk of hypoglycaemia
29
What condition is associated with initial few weeks painful goitre, ESR and hyperthyroidism followed by hypothyroidism and raised ESR? And what is management?
Subacute thyroiditis (de Quervain's)
Self-limiting (steroids if severe)
30
Side effects of metformin (biguanides)?
GI upset, lactic acidosis in those with renal failure
31
Primary hyperparathyroidism characteristics
```
Elderly lady with:
Renal stones
Bone pain
Peptic ulceration/constipation
Renal stones
Depression
Polydipsia, polyuria
```
Associated with:
HTN
MEN I and II
32
Addison's characteristics
Lethargy, weakness, anorexia, nausea, vomiting, abdominal pain, salt craving, muscle wasting
Hyperpigmentation of palmar creases and mucous membranes, vitiligo, loss of pubic hair
Hyperkalaemia, hyponatraemia, hypoglycaemia, hypotension
33
Toxic multinodular goitre characteristics and management
Autonomously functioning nodules in thyroid resulting in hyperthyroidism
Patchy uptake with nuclear scintigraphy
Radioiodine therapy
34
Thyrotoxicosis treatment
Propanalol for symptom management
Carbimazole (reduces thyroid hormone production) - agranulocytosis risk
Radioiodine treatment
35
What drug can cause thyrotoxicosis?
Amiodarone
36
40-year-old patient with a history of hypertension presents with episodic palpitations, excessive sweating, headaches and tremor
Pheochromocytoma
37
What is pheochromocytoma?
Catecholamine secreting tumour associated with MEN II and neurofibromatosis
Hypertension, palpitations, sweating, headaches, anxiety
38
Investigation and management of pheochromocytoma
24 hr urinary collection of metanephrines
```
Alpha blocker (phenoxybenzamine)
Beta blocker (propanalol)
Surgery 10 days later to remove tumour
```
39
Pioglitazone side effects
```
Weight gain
Fluid retention (DONT GIVE IN HEART FAILURE)
Liver impairment (monitor LFTs)
Risk of bladder cancer
Risk of fractures
```
40
Action and side effects of GLP-1 agonists (-tides)
Incretin mimetic which inhibits glucagon secretion and enhance glucose-dependent insulin secretion
SEs: Nausea, vomiting, weight loss and pancreatitis
41
A patient presents with muscle cramping and perioral paraesthesia two months after having thyroid surgery - primary hypoparathyroidism
Primary hypoparathyroidism
42
Treatment of hypoparathyroidism
Alfacalidol
43
MEN I features
Peptic ulceration, hypercalcaemia, galactorrhoea
44
MEN I endocrine organs?
3 Ps
Pituitary
Pancreas (Zollinger Ellison - ulcers/gastric acid; insulinoma)
Parathyroid
(also adrenal and thyroid)
45
2-month-old baby is noted to have hypotonia, macroglossia and a puffy face. They were treated at birth for neonatal jaundice
Congenital hypothyroidism
46
newborn baby is noted to have ambiguous genitalia. At 2 weeks they develop severe vomiting, dehydration and weight loss
Congenital adrenal hyperplasia
47
Klinefelter's syndrome characteristics
```
Small, firm testes
Raised gonadotrophin levels, but low testosterone
Above average height
Ambiguous secondary characteristics
Infertile
Gynaecomastia
```
Dx by karyotype testing (karyotype 47 XXY)
48
hypokalaemia, hypertension, alkalosis, no similar family history, raised aldosterone
Conn's Syndrome
49
a baby is born with ambiguous genitalia, exhibiting labioscrotal folds with clitoromegaly. At 13 years of age the child undergoes virilization with facial hair and deepening of the voice
5-alpha reductase deficiency
50
tall, slim 18-year-old man presents with hypogonadism. He also complains of anosmia. Gonadotrophin levels are reduced
Kallman's Syndrome
51
Features of congenital hypothyroidism
```
Prolonged neonatal jaundice
Delayed mental and physical milestones
Puffy face
Macroglossia
Hypotonia
Short stature
```
52
hypokalaemia, hypertension, alkalosis, family history of similar problems, low aldosterone
Liddle's syndrome
53
Conn's syndrome features
```
No family hx
Hypokalaemia
Hypertension
Alkalosis
Raised aldosterone
```
54
De Quervain's/subacute thyroiditis phases
Phase 1 (3-6 weeks): thyrotoxicosis, raised ESR, painful goitre (viral illness)
Phase 2 (weeks): euthyroid
Phase 3 (months): hypothyroidism
Phase 4: back to normal
55
What effect does cortisol have on kidneys and electrolytes?
Increases water and sodium retention
Increases potassium excretion
Hypokalaemic metabolic alkalosis
56
Myxoedema coma features
```
Confusion and fatigue
Hypothermia
Ankle swelling
Reduced respiratory rate and HR
Initial diastolic HTN followed by hypotension
Hair thinning
Cool dry skin
```
57
Myxoedema coma precipitating factors and treatment
Viral illness
Amiodarone
Beta blockers
Surgery, stroke, trauma
Tx: IV thyroid replacement, steroids, fluid
Correct electrolyte imbalances
58
Thyroid cancer with worst prognosis
Anaplastic (elderly patients)
59
Most common thyroid cancer and characteristics
Papillary
Young females, cervical lymph node mets
Thyroglobulin used as tumour marker
Characteristic Orphan Annie eyes on light microscopy
60
Follicular thyroid cancer characteristics
>50 females
Lung and bone mets
Thyroglobulin used as tumour marker
Usually solitary nodule
61
Addison's treatment
Hydrocortisone (glucocorticoid): 15-30mg in divided doses (should follow work pattern for shift workers)
Fludrocortisone (mineralocorticoid): 50-300mcg (adjusted to exercise levels and metabolism)
MedicAlert bracelet and steroid card
Double hydrocortisone during illnesses
62
T1 diabetic blood glucose targets
4-7mmol/L before meals
| 5-7mmol/L on waking
63
Addisonian crisis causes, features and treatment
Sepsis or surgery; infection in Addison patient; adrenal haemorrhage; abrupt withdrawal of steroids (most common)
Confusion with - hyponatraemia, hypotension, hypoglycaemia, hyperkalaemia, dehydration
100mg IV hydrocortisone and 1L saline (with dextrose if hypoglycaemic).
Continue hydrocortisone 6 hourly until stable. Oral replacement after 24 hours.
Monitor electrolytes
Fludrocortisone added for long--term management
64
Causes of Addison's
Autoimmune adrenalitis (developed countries)
TB (worldwide)
Metastises
Amyloidosis
65
Causes and features of DKA
Causes: missed insulin, infection, MI
Features: vomiting, abdominal pain, polyuria, polydipsia, dehydration, Kussmaul breathing, acetone breath smell
66
Diagnostic criteria for DKA
Blood glucose >11mmol/L or known DM
pH <7.3
Bicarbonate <15mmol/L
Ketones >3mmol/L or ++ on urine
67
Initial DKA management
1L normal saline over an hour (add potassium for following hours)
Insulin: O.1ml/kg/hour - when BM <15mmol/L then start 5% dextrose
Long-acting insulin continued
68
What are young DKA patients at risk of with treatment, what are the features and how should you adapt?
Risk of cerebral oedema - headache, irritability, visual disturbance, focal neuropathy
Give slower infusion
CT scan if suspected
69
When should you replace potassium in DKA?
<5.5mmol/L
70
Complications of DKA and its treatment
Gastric stasis
AKI
Arrhythmias secondary to hyperkalaemia/hypokalaemia
Incorrect fluid management leading to hypokalaemia, hypoglycaemia or cerebral oedema
ARDS
71
What characteristics would you see in someone with congenital adrenal hyperplasia?
Early menarche, hirsutism, large stature (virilization - in response to low cortisol pituitary produces raised levels ACTH, leading to increased adrenal androgen production)
Low cortisol, low sodium, raised potassium
72
What is the commonest cause of congenital adrenal hyperplasia?
Deficiency of 21-hydroxylase enzyme (responsible for aldosterone and cortisol synthesis)
73
How often should HbA1C be monitored in T1 diabetics and what should the target be?
Every 3-6 months
| Below 48mmol/mol
74
How often should a T1 diabetic with well-controlled BM be monitoring blood glucose?
4 times a day including before each meal and before bed
Increase during illness, if hypoglycaemic episodes increase, when planning pregnancy, during pregnancy and breastfeeding
75
Diagnosis of T2 diabetes?
Random glucose >11.1mmol/mol
Fasting glucose >7mmol/mol
HbA1C >48mmol/L (if symptomatic)
If asymptomatic need 2 readings
76
Indications for prescribing growth hormone therapy?
Prader-Willi syndrome
Turner Syndrome
Chronic renal insufficiency before puberty
Proven growth hormone deficiency
77
Adverse effects of growth hormone therapy
Headaches
Benign intracranial hypertension
Fluid retention
78
Turner syndrome signs and symptoms
```
PRIMARY AMENORRHOEA (fibrosed ovaries)
HYPOTHYROIDISM (and other AI conditions)
Bicuspid aortic valve or coarctation of the aorta
Webbed neck
Lymphoedema in neonates
Low set ears
Wide spaced nipples
Horseshoe kidney
```
79
Test to differentiate between T1 and T2 diabetes
C-peptide (low in T1 as pancreas not making enough insulin precursor which breaks down into C-peptide and insulin; normal/high in T2)
80
Advice for T1 diabetics during illness?
Monitor blood glucose more frequently
Continue same insulin doses
Monitor urinary ketones every 4 hours
81
What type of drug is sitagliptin and when would you add it to a regimen?
DDP-4 inhibitor (doesn't cause weight gain)
| If a thiazolidinedione is contraindicated due to weight or poor response
82
What is GLP-1?
Glucagon-like peptide 1, produced by the small intestine in response to raised glucose levels
GLP-1 is an analogue
DDP-4 inhibits its breakdown
83
Give an example of a GLP-1 and its adverse effects
Exenatide
Nausea and vomiting
Causes weight loss
84
Hyperosmolar Hyperglycaemic State characteristics
T2 diabetic
General: lethargy, vomiting, recurrent infections
Neurological: headaches, papilloedema, reduced consciousness, weakness
CV: dehydration, hypotension, tachycardia
85
HHS diagnosis
```
Raised blood glucose >30mmol/mol
Mild ketonaemia (<3mmol/mol)
Hypovolaemia
Raised serum osmolarity
pH >7.3 (less acidotic than DKA)
```
86
HHS management
0.9% saline to reduce osmolality and replace fluids (use 0.45% if osmolarity not restoring)
Monitor osmolarity, sodium and glucose on a graph
Target glucose: 10-15mmol/mol
87
When should you give insulin to HHS patient?
ONLY if significant ketonaemia
88
What is the inheritance pattern of maturity onset diabetes of the young?
Autosomal dominant
89
Characteristics of MODY
<25
Family history
Ketosis rare
Sensitivity to sulfonylureas (insulin rarely needed)
90
What condition would give a lower than expected HbA1C?
Sickle Cell Anaemia due to reduced RBC lifespan
91
What conditions would give a higher than expected HbA1C? (due to increased RBC lifespan)
Vitamin B12/folic acid deficiency
Splenectomy
Iron-deficiency anaemia
Alcoholism
92
Main carbimazole side effect
Agranulocytosis
93
Management of Graves'
Anti-thyroid (carbimazole) followed by thyroxine when euthyroid
Radioiodine treatment
Propanalol to block adrenergic effects
94
Radioiodine treatment contraindications and side effects
Pregnancy (don't get pregnant at least 4-6 months after treatment)
Thyroid eye disease (precipitates)
Side effects: thyroid eye disease, hypothyroidism
95
Common non-diabetic causes of hypoglycaemia
```
EXogenous drugs (alcohol, quinine, ACE-i)
Pituitary insufficiency
Liver failure
Addison's disease
Islet cell tumours (insulinoma)
Non-pancreatic neoplasms
```
96
Management of subclinical hypothyroidism
>65 - watchful waiting
<65 and symptomatic - start trial of levothyroxine
If >10mU/L of TSH and asymptomatic - start levothyroxine (unless elderly)
Asymptomatic - repeat TFTs in 6 months
97
Definition of subclinical hypothyroidism
raised TSH, normal T3 and T4
| Asymptomatic
98
What are the main effects of a pituitary adenoma?
Excess of hormones (e.g. Cushing's disease, acromegaly or excess prolactin)
Depletion of hormones due to compression of pituitary
Stretching of dura (headaches)
Compression of optic chiasm (bitemporal hemianopia)
99
Investigations for pituitary adenomas
Pituitary blood profiles: GH, ACTH, prolactin, FSH, LH, TFTs
Formal visual fields
MRI brain
100
What is CA 19-9 a marker for?
Pancreatic cancer
101
What hormone do medullary cancers usually produce?
Calcitonin
102
What is gliclazide and what side effects are there?
Sulfonylurea
Weight gain and hypoglycaemia
103
Management of thyroid patient with visual changes?
Urgent specialist review (especially loss of colour vision)
104
Type 1 diabetic with bloating, vomiting, and impaired glucose control - diagnosis and management
Gastroparesis (neuropathy of vagus nerve)
Mx: Metoclopramide or erythromycin
105
What is Whipple's triad and what does it diagnose?
Symptoms and signs of hypoglycaemia
Hypoglycaemia (<2.5mmol/L)
Reversibility of symptoms on administration of glucose
INSULINOMA
C-peptide levels do not fall on insulin administration (endogenous levels are not reduced)
106
Effect of insulin
Causes liver, skeletal muscle and fat cells to absorb glucose
Liver and skeletal muscle: glycogen
Fat cells: triglycerides
107
Causes of raised prolactin
```
Pregnancy
Prolactinoma
Physiological
PSCOS
Primary hypothyroidism
Phenothiazines, metocloPramide, domPeridone
```
108
High calcium, high or inappropriately normal PTH
Primary hyperparathyroidism
109
Cause of secondary hyperparathyroidism
Chronic hypocalcaemia e.g. CKD
| Low or normal calcium and high PTH
110
Cause of tertiary hyperparathyroidism
Secondary hyperparathyroidism resulting in autonomous PTH secretion (end-stage renal disease patients)
high PTH
Mildly raised calcium
111
What should T2 diabetics be given when started on insulin
Glucagon kit for hypos
| Also should have sweets or juices ready
112
Most common presentation of MEN I
Hypercalcaemia
113
MEN IIa and b associations
Medullary thyroid cancer, phaeochromocytoma and RET oncogene
IIa: hyperparathyroid
IIb: marfanoid body habitus, neuromas
114
T2 diabetic on lifestyle changes target glucose
48
115
T2 diabetic with lifestyle and metformin target
48
116
T2 diabetic on one drug but HbA1C increased to >58 - whats the target?
53
117
What is the gene in MEN I
MEN gene
118
How can you distinguish between an insulinoma and someone injecting insulin?
Insulinoma: high c-peptide
| Exogenous insulin: low/normal c-peptide
119
What are the DVLA restrictions for a diabetic on insulin who wants an HGV license?
No severe hypoglycaemic episodes in past 12 months
Full hypoglycaemic awareness
Good glucose control, with twice daily monitoring and at times relevant to driving
No other debarring complications
120
Klinefelter's syndrome blood results
High gonadotrophins (FSH/LH)
Low testosterone
PRIMARY HYPOGONADISM
121
What is the CT head finding on the skull with hyperparathyroidism?
Pepper pot skull
122
What is the purpose of Kussmaul breathing
Deep and laboured to expel excess CO2 with metabolic acidosis
123
DKA blood results
Hyponatraemia
Low bicarbonate
Normal-high potassium (although insulin therapy can cause hypokalaemia and arrhythmias)
124
What is Zollinger-Ellison Syndrome and when might you see it?
Gastrin-secreting tumour in the islet cells of the pancreas or duodenal wall leading increased HCl production gastric antrum. This results in duodenal ulcers.
Seen in MENI
125
Insulin side effects
Weight gain, lipodystrophy, hypoglycaemia
126
Name an aldosterone antagonist given to someone with bilateral adrenal hyperplasia
Spironolactone
127
What is the primary action of orlistat?
Pancreatic lipase inhibitor (decreases breakdown and absorption of lipids)
128
Side effects of thyroxine treatment
Hyperthyroidism
Reduced bone mineral density
Exacerbation of angina
AF
129
T2 BP targets (end organ and no end organ damage)
No end organ damage: <140/80
| End organ damage: <130/80
130
What is Trosseau's sign?
Hypocalcaemic patient
| On inflation of BP cuff past systolic, wrist flexes and fingers adduct
131
OGTT at 2 hours for impaired glucose tolerance?
7.8-11.1 mmol/mol
132
How do thyroid problems affect periods?
Hyperthyroidism: amenorrhoea or oligomenorrhoea
Hypo: menorrhagia
133
Most common cause of primary hyperparathyroidism?
Solitary parathyroid adenoma
134
What can ACTH be cleaved into, and what does that then effect?
melanocyte stimulating hormone resulting in hyperpigmentation (especially of oral mucosa and palmar creases)
135
Highest and lowest points of cortisol levels?
Highest: 8am
Lowest: midnight/1am
136
What causes an increase in renin levels?
Renal artery hypotension
Sympathetic nervous stimulation
Reduce sodium levels in distal tubule
137
What is renin's action?
Cleaves angiotensinogen into angiotensin I
138
Role of ACE and where is it found?
Converts angiotensin I into angiontensin II
| Found in vascular epithelium of the lung
139
Angiotensin II function?
Stimulates ADH release
Sodium reabsorption
Aldosterone (mineralcorticoid) release
Vasoconstriction
140
What is aldosterone released in response to, and what are its effects?
Release due to: angiotensin II, ACTH, potassium levels
Effects: increases number of epithelial sodium channels in distal tubule - sodium and water reabsorption, potassium excretion
141
Causes of adrenal insufficiency?
Worldwide: TB
Developed: autoimmune (destruction of 21-hydroxylase)
Rarer: metastases, HIV, meningococcal sepsis (causing haemorrhage), amyloid deposits, bilateral adrenalectomy
142
Investigations for Addison's
8am cortisol level:
< 100 nmol/L: admit to hospital
100–500 nmol/L: refer for synacthen test, consider admission if symptoms are severe
> 500 nmol/L: Addison’s is unlikely
143
What is the synacthen test?
```
250mcg tetracosactide (synacthen)
Cortisol measured at 0, 30 and 60 mins
```
Should be >430 nmol/L
144
Different adrenal cortex layers and what they produce
Zona glomerulosa - mineralcorticoids
Zona fasciculata - glucocorticoids
Zona reticularis - androgens
145
What is the adrenal medulla responsible for producing?
Catecholamines (derived from tyrosine)
- dopamine
- adrenaline
- noradrenaline
146
Cushing's syndrome signs and symptoms
Head: buffalo hump, facial flush, moon face
Body: hypertension, oedema, muscle wasting, acne, thin skin, striae,
Symptoms: lethargy, weight gain, depression, easy bruising, amenorrhoea, reduced libido
147
Cushing's treatment
Medical: metyrapone (11beta-hydroxylase inhibitor - reduces cortisol)
Surgical: transphenoidal pituitary resection, adrenalectomy, ectopic tumour excision
148
Cushing diagnosis - primary investigations
24 hour urinary cortisol
Midnight cortisol
Low dose dexamethasone
149
How does cortisol lead to osteopenia?
Inhibits osteoblast activity
| Inhibits vitamin D so reduces calcium reabsorption in intestines
150
Gigantism definition
Excessive GH secretion in childhood before epiphyseal fusion: height >2sd for patient's age and sex
151
Where is IGF-1 released from and what effect does it have on GH?
Released from liver
Negative feedback on GH
Stimulates somatostatin (which also is a negative regulator of GH)
152
Signs and symptoms of acromegaly
Mass effect: visual changes and headaches
Face: enlarged lips and nose, wide spaced teeth, deep skin creases
Body: large hands and feet, hyperpigmentation, aganthosis nigricans
Carpal tunnel syndrome
Increased risk of arrhythmias, hypertension, cardiomyopathy
153
What cancer are you more at risk of in acromegaly?
Colorectal
154
Gigantism features?
Mass effect: visual changes and headaches
Face: frontal bossing, coarse facial features
Obesity, tall stature, large hands and feet
155
Acromegaly investigations
Serum IGF-1
Oral glucose tolerance test: 100g oral glucose, measure GH before and after (should be suppressed below <0.6mcg/L if normal)
MRI pituitary
156
Acromegaly management
1. Surgical (microadenomas more successful, recurrence of all adenomas is 10%)
2. Radiotherapy (usually combined with medical therapy, risk of hypopituitarism - avoid if reproductive age)
3. Medical therapy:
somatostatin receptor agonists (octreotide) bridge to surgery
dopamine agonist (bromocriptine) shrink tumours
GH antagonists
157
Effects of growth hormone
Increased lipolysis, protein synthesis and gluconeogenesis
Increased bone mineralisation
IGF-1 release
158
Causes of carpal tunnel syndrome
```
Pregnancy
Rheumatoid arthritis
Acromegaly
Glucose
Mechanical (e.g. fractures)
Amyloid deposits
Thyroid underactive
Infection
Crystals (gout)
```
159
T2 diabetic with hypoglycaemia and low GCS - management?
100ml of 20% Glucose IV
| Buccal glucose if normal GCS
160
Features seen in Graves but not other hyperthyroidism causes
Eye disease (exophthalmos, ophthalmoplegia, glaucoma, proptosis)
Thyroid acropachy (soft tissue swelling of hands and feet, clubbing, periostitis)
Pretibial myxoedema (mucopolysacharide deposition)
161
Initial management of hypercalcaemia
3-4L IV saline
| Bisphosphonates
162
Complications of thyroidectomy
Laryngeal nerve palsy (hoarse voice)
| Hypoparathyroidism --> hypocalcaemia (tingling peripheries)
163
Effects of thyroxine on the body
BMR: increases Basal Metabolic Rate
Heart: increases heart rate and contractility (increases sensitivity to catecholamines)
Growth: increases release and effect of GH and IGF-1
Metabolism: anabolic at low levels, catabolic at high levels
164
Hyperthyroid causes of thyrotoxicosis
Grave's
Toxic multinodular goitre
Solitary toxic adenoma
Amiodarone-induced thyrotoxicosis type 1 (increased iodine uptake)
Pituitary adenoma
Beta-HCG (mimics TSH) - pregnancy, hydatidiform mole
165
Causes of thyrotoxicosis without hyperthyroidism
De Quervain's (inflammation of thyroid)
Amiodarone-induced thyrotoxicosis type 2 (destructive thyroiditis)
Levothyroxine
Follicular thyroid cancer
166
Grave's symptoms
Goitre
Proptosis, lid lag, ophthalmoplegia, dry eyes
Visual loss
Fine tremor
Sweating
Palpitations, tachycardia, arrhythmia, high output cardiac failure
Hyperreflexia
Hyperdefacation, weight loss, increased appetite
Pretibial myxoedema
Oligomenorrhoea, menorrhagia
167
Grave's ophthalmopathy classification
```
No signs or symptoms
Only signs
Soft tissue involvement
Proptosis
Extra ocular involvement
Corneal involvement
Sight loss
```
SPECS- refer, steroids, irradiation, surgical decompression
168
Subclinical hyperthyroidism
Low TSH
| Normal T4
169
Radiodine treatment risks
Increased risk of Graves' eye disease
| CI in pregnancy or breastfeeding
170
Thyrotoxic crisis presentation
Hyperthermia, nausea, vomiting, hypertension, tachycardia, arrhythmias, seizures, cognitive decline
171
Thyrotoxic crisis management
Beta blockers
Thionamides (propylthiouracil) - antithyroid and blocks T4 conversion to T3
Corticosteroids - blocks T4 to T3 conversion
Dialysis or plasma exchange may be required
172
What is your treatment of choice for a woman in 1st trimester of pregnancy with thyrotoxicosis
Propylthiouracil (change to carbimazole in 2nd trimester as prop assoc with liver injury)
Dose titration (NOT block and replace)
173
What are beta blockers in pregnancy associated with?
IUGR
Fetal bradycardia
Neonatal hypoglycaemia
174
Who can't you give pioglitazone (thiazolidinediones)?
Someone with heart failure
175
Which steroid has least mineralocorticoid (fluid-retention) activity and when would you use it?
Dexamethasone (anti-inflammatory)
| Raised ICP secondary to brain tumour
176
First line treatment for diabetic neuropathy?
Amitriptyline. pregabalin, gabapentin, duloxetine
Tramadol as rescue therapy for exacerbations
Capsaicin for localised neuropathic pain
177
After metformin, what drug would you generally give to a non-obese patient and why? Who would you avoid it in?
Sulfonylurea (gliclazide) as most effective at reducing blood glucose
Avoid if patient need to avoid hypoglycaemia (e.g. professional drivers) as risk of hypoglycaemia
178
HbA1c target if patient on a drug with hypoglycaemic risk?
53
179
Which hormones are reduced in the stress response?
Insulin
Oestrogen
Testosterone
180
Which blood pressure medication is given to patients diagnosed with phaeochromocytoma and why?
Labetalol
| Has both beta and alpha blocker mechanism (reduces cardiac output and peripheral vascular resistance)
181
Why might a patient with long-standing T1 diabetes have reduced hypoglycaemic awareness?
Neuropathy of the autonomic nervous system
182
Potassium management in patient with DKA
>5.5: none
3.5-5.5: 40
<3.5: specialist review
Start giving potassium along with IV fluids after first hour
183
When should you add dextrose to DKA management?
Blood glucose <15mmol/L
184
When should you add metformin to a T1 diabetic's management?
BMI >25
185
Initial management of T1 diabetic
Basal-bolus insulin regimen with twice-daily insulin detemir
186
Treatment of choice for maturity onset diabetes in the young (with HNF-1 alpha)?
Sulfonylurea (gliclazide)
187
Causes of gynaecomastia
Testicular failure or cancer (e.g. mumps)
Ectopic tumour secretion
Physiological with puberty
Drugs (spironolactone, digoxin)
Liver disease
Hyperthyroidism
Syndromes with androgen deficiency (Klinefelters, Kallmans)
188
Management of pituitary incidentaloma?
Lab screening for hormone secretions - is it functional or non-functional??
189
Indications for surgical removal of pituitary tumour?
Hypersecreting tumour (other than prolactinoma)
Visual disturbance
Pressure on optic nerves or chiasm
Pituitary apoplexy
190
How many units of insulin in 1ml?
1000
191
Causes of pseudo Cushings
Alcohol abuse
| Depression
192
What electrolyte is necessary for PTH secretion, and thus what effect will a deficiency of it have on calcium levels?
Magnesium
| Low magnesium results in low calcium
193
Characteristics of benign adenomas?
Lipid-rich core
| Well-circumscribed
194
Diabetes inspidus treatment
Desmopressin
195
Pituitary apoplexy
Headache and visual field loss
Investigations: bloods, visual fields, MRI and CT
Treatment: hydrocortisone 100mg bolus (followed by 50-100 doses)
196
Complication of transsphenoidal surgery?
Postoperative diabetes insipidus
197
Drug causes of hyponatraemia
```
Omeprazole
Sodium valproate, carbamazepine
Diuretics/ace-i
Desmopressin
Sertraline
Ecstasy
```
198
Medical causes of hyponatraemia?
All organ failures (liver, cardiac, kidney, thyroid, adrenal)
199
A 19-year-old lady is admitted to ITU with severe meningococcal sepsis. She is on maximal inotropic support and a CT scan of her chest and abdomen is performed. The adrenal glands show evidence of diffuse haemorrhage.
Waterhouse-Friderichsen Syndrome
200
Which steroid has the most glucocorticoid (anti-inflammatory) activity and least mineralocorticoid (fluid retention)
Dexamethasone
